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Results for “Reimbursement, Incentive”

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PubMed2006

Are physician reimbursement strategies associated with processes of care and patient satisfaction for patients with diabetes in managed care?

OBJECTIVE: To examine associations between physician reimbursement incentives and diabetes care processes and explore potential confounding with physician organizational model. DATA SOURCES: Primary data collected during 2000-2001 in 10 managed care plans. STUDY DESIGN: Multilevel logistic regressions were used to estimate associations between reimbursement incentives and process measures, including the receipt of dilated eye exams, foot exams, influenza immunizations, advice to take aspirin, and assessments of glycemic control, proteinuria, and lipid profile. Reimbursement measures included the proportions of compensation received from salary, capitation, fee-for-service (FFS), and performance-based payment; the performance-based payment criteria used; and interactions of these criteria with the strength of the performance-based payment incentive. DATA COLLECTION: Patient, provider group, and health plan surveys and medical record reviews were conducted for 6,194 patients with diabetes. PRINCIPAL FINDINGS: Without controlling for physician organizational model, care processes were better when physician compensation was based primarily on direct salary rather than FFS reimbursement (four of seven processes were better, with relative risks ranging from 1.13 to 1.23) or capitation (six were better, with relative risks from 1.06 to 1.36); and when quality/satisfaction scores influenced physician compensation (three were better, with relative risks from 1.17 to 1.26). However, these associations were substantially confounded by organizational model. CONCLUSIONS: Physician reimbursement strategies are associated with diabetes care processes, although their independent contributions are difficult to assess, due to high correlation with physician organizational model. Regardless of causality, a group's use of quality/satisfaction scores to determine physician compensation may indicate delivery of high-quality diabetes care.

Diabetes Mellitus↗
PubMed2000

Financial reimbursement: an incentive to increase the supply of transplantable organs.

The medical need for human organs suitable for transplantation far exceeds the current supply of organs and continues to grow. A perception exists that minorities, specifically African Americans, are not donating organs at a rate consistent with their representation of the national population. Cadaveric donor data from 1995 reveals that 11.4% of the donors were African American, 9.1% were Hispanic, and 1.5% were of Asian origin. The purpose of this study was to explore the hypothesis that financial reimbursement would increase organ donation among potential donors who are hesitant to donate for altruistic reasons alone.

Adolescent↗
PubMed2004

Addressing government and market failures with payment incentives: Hospital reimbursement reform in Hainan, China.

This paper examines the role of provider payment policy as an instrument for addressing government and market failures and controlling costs in the health sector, particularly in developing countries. We empirically evaluate the impact of provider payment reform in Hainan province, China, on expenditures for different categories of services that had been subject to distorted prices under fee-for-service. Using a pre-post study design with a control group, we analyze two years of claims data to assess the impact of a January 1997 change to prospective payment for a sub-sample of the hospitals. This difference-in-difference empirical strategy allows us to isolate the supply-side payment reform effects from demand-side policy interventions. We find that prepayment is associated with a slower increase in spending on expensive drugs and high technology services, compared to fee-for-service. The fact that payment reform is associated with reduced growth in spending on the most expensive drugs is particularly encouraging, given that drugs account for a remarkably high percentage of both the level and growth of aggregate health expenditure in China. Payment reform can be an effective policy instrument for correcting market failures and adverse side effects of government health sector interventions (such as distorted prices to assure access to basic services), both of which can lead to excessive health care expenditure growth. Such health spending growth can have a particularly high opportunity cost for developing countries.

China↗
PubMed2006

Do religious nonprofit and for-profit organizations respond differently to financial incentives? The hospice industry.

We study how for-profit and religious nonprofit hospices respond to an exogenous Medicare reimbursement incentive that encourages maximization of patient length of stay. Hospices have the incentive to selectively admit patients with longer expected lengths of stay, and admit patients sooner after a hospital discharge. We find that for-profit hospices are significantly less likely to admit patients with shorter, less profitable, expected lengths of stay. We do not find any difference in the timing of admission by ownership. Incentives for efficiency could be strengthened by a Medicare pricing system that replaced the current flat per diem payment with one that reflected the high costs at the beginning and end of hospice stay and the lower costs in between.

Aged↗
PubMed1998

Supporting child psychiatric services using current managed care approaches: you can't get there from here.

For-profit behavioral health care companies have transformed the way mental health services are provided for children. Using marketplace approaches, companies have "carved out" mental health services for many patients receiving care from pediatricians. This report details specific approaches used by these firms to maximize profits, minimize the role of child and adolescent psychiatrists, and limit clinical services. Understanding for-profit carveouts will help primary care pediatricians appreciate the likely consequences of such reimbursement incentives for the care of children and their families.

Adolescent↗
PubMed1995

Accounting for the transition from inpatient to outpatient surgery.

This article reports on some of the factors that have advanced and impeded hospital progress in moving from inpatient to outpatient surgery. Early on, patients, physicians, and hospital administrators all agreed that outpatient surgery had an intuitive appeal. Patients liked it because they didn't have to go in the hospital. Physicians liked it because they could get in and out of the outpatient surgery center more easily than the main hospital operating room. Administrators recognized the inherent appeal of outpatient procedures but were unable or unwilling to switch services from inpatient to outpatient for a variety of reasons. First, empty hospital beds and diminished scope of inpatient operations are a threat to the power of administrators. Moving surgery from inpatient to outpatient settings reduces inhouse operations. Second, reimbursement incentives were definitely in favor of continued inpatient care long after technology was in place for outpatient care. The third and most critical reason was that cost data on outpatient operations were just not available for making decisions on when to move into the outpatient setting. This review of the literature was intended to document the lack of relevant cost-based accounting. Instead, many other factors that more directly slowed progress were encountered. More than anything, this illustrates the erratic course of progress in health care reform.

Ambulatory Surgical Procedures↗
PubMed1998

Creaming, skimping and dumping: provider competition on the intensive and extensive margins.

Reimbursement incentives influence both the intensity of services and who is treated when patients differ in severity of illness. The social optimum is compared to the private Cournot-Nash solution for three provider strategies: creaming--over-provision of services to low severity patients; skimping--under-provision of services to high severity patients; and dumping--the explicit avoidance of high severity patients. Cost-based reimbursement results in overprovision of services (creaming) to all types of patients. Prospectively paid providers cream low severity patients and skimp high severity ones. If there is dumping of high severity patients, then there will also be skimping.

Economic Competition↗
PubMedDate not supplied

Peritoneal dialysis in Ontario: a natural experiment in physician reimbursement methodology.

BACKGROUND: The factors that determine dialysis modality selection and distribution are not well understood. Physician reimbursement incentives have been suggested to play an important role. Under the fee-for-service system in Ontario that existed prior to July 1998, nephrologists were paid about sevenfold more for a hemodialysis (HD) patient than for a patient on peritoneal dialysis (PD). However, since then, nephrologists have been reimbursed via a modality-independent capitation fee, whereby payment for any form of dialysis is the same. This was expected to markedly increase the use of PD. METHODS: When the capitation fee was introduced in 1998, a survey questionnaire of all Ontario nephrologists was done and repeated 3 years later (response rate 62.5%). Changes in dialysis modality incidence and prevalence rates in Ontario and in the rest of Canada were examined. RESULTS: On a scale of 1 to 7, nephrologists were convinced that the capitation fee was a good thing (mean rating 6.07); 75% said they had been seeing patients at every dialysis under the old system, compared to 41% now. Of significance, the proportion of prevalent patients on PD in Ontario declined from 27.3% in 1997 to 19.7% in 2000, increasing to 22.6% in 2002. Similarly, the incident PD rate seems to have stabilized, while the use of nonhospital-based HD has increased. CONCLUSIONS: Following the introduction of the capitation fee, PD use in Ontario continued to decline for 2 years, and then began to increase. In the rest of Canada, there are continuing declines in PD use. This is consistent with the hypothesis that the new incentives caused by the altered physician reimbursement are acting in a subtle way to increase PD and non-hospital-based HD. A longer period of observation may be required to assess the complete effect.

Capitation Fee↗
PubMed1983

Paying the hospital: foreign lessons for the United States.

This special report synthesizes the findings of a Health Care Financing Administration grant which allowed the author to analyze hospital finance in six foreign countries and in the United States. The author identified the principal problems facing hospital owners, carriers, and governments in the United States, and he conducted lengthy field work abroad to learn how each country dealt with the same problems. One set of the author's conclusions makes more clear issues that are debated in the United States, such as the meaning of "cost-based reimbursement" and "prospective reimbursement". Some of the author's findings show the difficulty of implementing policies often proposed in the United States, such as incentive reimbursement schemes. Other findings of the author show the conditions necessary for cost containment, such as strong representation of consumers and firm political will by government.

Costs and Cost Analysis↗
PubMed1989

Professional reimbursement and professional behavior: emerging issues and research challenges.

The decisions and actions of health care professionals have a major impact on such health care outcomes as cost, quality and equity. It is widely believed that professional behavior is determined, in part by how and how much they are paid. Professionals can respond to reimbursement incentives at both the individual level (treatment decisions, referral patterns, specialty choice, etc.) and at the level of the professional association. Health care analysts usually identify and discuss three principal reimbursement modes: salary, capitation, and fee-for-service. Mixed systems are proliferating and need to be evaluated. Payment levels are determined by a mix of equity, market, and political considerations. They are believed by many to influence the behavior of providers, who are thought to act so as to preserve target incomes. The target income hypothesis has been tested for the case of physicians operating in a fee-for-service environment. The impact of changes in reimbursement levels on the behavior of other groups of professionals and on the behavior of professionals working in other reimbursement modes remains unclear. Both policy-makers and researchers need to broaden the way in which they think about professional reimbursement. To date, the field has been dominated by economists, inquiry has focused heavily on physicians, and empirical work has emphasized those dimensions of outcome which are most easily measured. Changes in the organization of health services and in society-at-large intensify the need for a broader view.

Decision Making, Organizational↗
PubMed2005

Effect of physician reimbursement methodology on the rate and cost of cataract surgery.

OBJECTIVES: To compare the effects of 2 reimbursement methodologies, fee-for-service and contact capitation, on cataract extraction rates and costs in a stable physician population with little potential for the influence of patient selection. Previous research evaluating the relationship between physician reimbursement incentives and cataract surgical rates has been limited by physician and patient selection bias. METHODS: A pre-post analysis of claims and encounter data for an average of 91,473 commercial beneficiaries and 14,084 Medicare beneficiaries receiving eye care from a network of ophthalmologists and optometrists in St Louis, Mo, between 1997 and 1998. The rate of cataract extractions per 1000 beneficiaries, the costs of cataract procedures, the rates of noncataract procedures, and the level of professional reimbursement for providers were compared during the final 6 months of fee-for-service physician reimbursement and the first 6 months of contact capitation. RESULTS: Both commercial and Medicare beneficiaries were approximately one half as likely to have cataract extraction (P<.001) under contact capitation as compared with fee-for-service. Professional reimbursement increased by 8% whereas facility fees for cataract procedures decreased by approximately 45%. Cataract surgical rates were disproportionately affected when compared with other ophthalmologic procedures. During the study period, cataract surgical rates were stable in the national and Missouri traditional fee-for-service Medicare population. CONCLUSIONS: The stability of the physician and patient populations allowed us to isolate the effects of physician reimbursement methodology on practice patterns. Compared with fee-for-service, contact capitation reimbursement was associated with significant decreases in cataract extraction rates and costs. The frequency of the cataract extraction surgery, the most common major elective procedure in ophthalmology, was more responsive to physician financial incentives than other ophthalmologic procedures were.

Capitation Fee↗
PubMed1990

The Ventilator-assisted Individuals Study.

A paucity of reliable data exists concerning ventilator-assisted individuals (VAIs) for program planning. The Chicago Lung Association, with funding from Blue Cross/Blue Shield of Illinois, conducted a community action project to determine the magnitude of the issues in Illinois. The purposes of the VAI Study were to ascertain needs and resources, generate recommendations, and recruit community involvement. The survey identified 453 VAIs: 145 in hospitals, 105 in extended-care facilities, and 203 at home. A majority (62 percent) of hospitals provided services to VAIs; many more would with proper reimbursement incentives. Only 60 percent of hospitals serving VAIs had active discharge teams; discharge was accomplished by a variety of mechanisms and personnel. Monthly hospital charges averaged $22,190 with a range from $10,020 to $66,750 depending on the location of the patient. Most reimbursement was public; private funding was fragmented. Major discharge barriers were inadequate payment for community-based services, limited community resources, constrained consumer's finances, and lack of access to information. Recommendations for future community action included establishing a technology transfer system, home care case management, an integrated management system, a documentation center, and trials and demonstrations prior to program and policy development.

Adult↗
PubMed1999

Effect of incentives on the use of indicated services in managed care.

In managed care, financial incentives and utilization review create conflicts of interest for physicians. We sought to determine whether these incentives would lead physicians to deny indicated services. We surveyed internists practicing in areas with at least 30% penetration of managed care. Our questionnaire included four scenarios in which a test or referral is indicated according to clearly established practice guidelines. We randomly assigned physicians to receive one of five versions of the questionnaire, which differed only in the type of reimbursement incentive and utilization review that applied to the scenarios. We received responses from 710 (70%) of 1,009 internists. Although physicians underutilized services regardless of incentives in all scenarios, physicians whose questionnaires depicted full capitation said that they would order fewer services than physicians whose questionnaires depicted fee-for-service. In the scenario in which an x-ray of the lumbosacral spine is indicated for a patient with low back pain, 86% of physicians randomized to the full capitation version said that they would order the test compared to 94% in the fee-for-service version. Similarly, physicians randomized to scenarios requiring utilization review said that they would order fewer services than those randomized to scenarios requiring completion of an insurance form. Scenarios depicting managed care incentives caused consistent, modest underutilization compared to fee-for-service scenarioes, although physicians underutilized services under all financial incentives and utilization review. In response, physicians must develop better methods for detecting underutilization and devise programs to increase the provision of indicated services.

Adult↗
PubMed1987

The key role of health insurance in a cost-effective health care system. Towards regulated competition in the Dutch medical market.

The previous two sessions of this Symposium have dealt with incentives for cost-effective provider behaviour. Although incentive-reimbursement, which rewards the providers for delivery medical care in a cost-effective way, can be an important step towards a cost-effective health care system, it is not rewards the providers for delivering medical care in a cost-effective way, can be an important step towards a cost-effective health care system, it is not sufficient. As long as the insured consumers have both comprehensive health insurance coverage and freedom of choice of provider, providers will have great difficulty in resisting consumers' demand for ever more costly medical care, and politicians or other decision-makers will have great difficulty in restricting capacity and in preventing overcapacity. Fear of losing patients or voters might dominate. Therefore, in this session we shall focus on the key role of health insurance in a cost-effective health care system and on consumer incentives and insurer behaviour. If the consumers have a choice between several provider-insurer organizations. Although market forces do play an important role in a competitive health-care system, competition should not be confused with a "free market". Besides financial arrangements to protect the poor, pro-competitive regulation is needed to guarantee a "fair competition". Currently there is much consensus that the present Dutch health insurance system, in which 60% of the population is publicly insured and 40% is privately insured, should be replaced by a national health insurance scheme, which uniformly applies to the entire population. A few years ago, I made a proposal for such a scheme, which was based largely on the ideas of Ellwood, McClure, and Enthoven on competition between alternative delivery systems. The main features of this proposal will be discussed. In my opinion, the long-term prospects for regulated competition in the Dutch medical market seem rather favourable.

Choice Behavior↗
PubMed1998

Hysterectomy in a decade of change: more than a weighty matter.

Objective: Hysterectomy is the second most common surgical procedure performed in the United States. Interest to decrease use of hysterectomy has focused on developing explicit criteria for surgery, peer review and second opinion, as well as changing reimbursement incentives. The purpose of this study is to describe the change in the number of hysterectomies, the indications for hysterectomies, and the histopathology of hysterectomy specimens over the last 10 years at one private, nonprofit, academic, community hospital that does not have a formal system for monitoring hysterectomy use.Methods: Retrospective study utilizing administrative data matched with pathology reports for nonmalignant hysterectomies performed in 1985, 1990, and 1995. Uterine weight and histopathologic diagnoses were recorded. When pathology reports were unavailable, cases were reviewed to determine if the indication was related to prolapse or urinary incontinence. Outcome measures included number of procedures performed, indications for procedures and uterine pathology (uterine weight, histopathology). We utilized the Cochran-Mantel-Haenszel chi(2) and the Kruskal-Wallis rank sum statistic (P <.05).Results: The number of hysterectomies declined from 631 in 1985 to 461 in 1995 (P =.007). The median uterine weight increased (P =.0007), and there was a decrease in the number of specimens with absent histopathology, decreasing from 6% in 1985 to 3% in 1995 (P =.013). This difference was explained by changes in the number of procedures performed on patients with private insurance and HMO reimbursement (P =.018).Conclusions: While the proportion of surgeries performed for specific indications did not change, the number of hysterectomies performed decreased, and there were fewer normal specimens.

Journal Article↗
PubMed2005

Polio eradication: mobilizing and managing the human resources.

Between 1988 and 2004, the Global Polio Eradication Initiative grew to become the largest international health effort in history, operating in every country of the world. An estimated 10 million health workers and volunteers have been engaged in implementing the necessary polio supplementary immunization activities (SIAs) on a recurring basis, and at least 35,000 well-trained workers have been conducting polio surveillance. A combination of task simplification, technological innovations and adaptation of strategies to fit local circumstances has allowed the Initiative to use a wide range of workers and volunteers, from both inside and outside the health sector, to deliver the polio vaccine during SIAs and to monitor progress in virtually every area of every country, regardless of the health infrastructure, conflict, geography and/or culture. This approach has required sustained political advocacy and mass community mobilization, together with strong management and supervisory processes. Non-monetary incentives, reimbursement of costs and substantial technical assistance have been essential. Given the unique features of eradication programmes in general, and polio eradication in particular, the implications of this approach for the broader health system must continue to be studied if it is to be replicated for the delivery and monitoring of other interventions.

Community Health Planning↗
PubMed2001

How reliable are hospital efficiency estimates? Exploiting the dual to homothetic production.

For scientific use, stochastic frontier estimates of hospital efficiency must be robust to plausible departures from the assumptions made by the investigator. Comparisons of alternative study designs, each well within the 'accepted' range according to current practice, generate similar mean inefficiencies but substantially different hospital rankings. The three alternative study contrasts feature (1) pooling vs partitioned estimates, (2) a cost function dual to a homothetic production process vs the translog, and (3) two conceptually valid but empirically different cost-of-capital measures. The results suggest caution regarding the use of frontier methods to rank individual hospitals, a use that seems to be required for reimbursement incentives, but they are robust when generating comparisons of hospital group mean inefficiencies, such as testing models that compare non-profits and for-profits by economic inefficiency. Demonstrations find little or no efficiency differences between these paired groups: non-profit vs for-profit; teaching vs non-teaching; urban vs rural; high percent of Medicare reliant vs low percent; and chain vs independent hospitals.

Benchmarking↗